2025 ICD-10-CM code S01
(Active) Effective Date: N/A Injury - Injuries to the head (S00-S09) Injury, poisoning and certain other consequences of external causes (S00-T88) Feed
Open wound of head. Code also any associated injury of cranial nerve (S04.-), injury of muscle and tendon of head (S09.1-), intracranial injury (S06.-), or wound infection.
Use 7th character to specify initial encounter (A), subsequent encounter (D), or sequela (S).
Medical necessity is based on the severity and type of wound.Simple wounds may only require cleaning and dressing, while complex wounds with significant bleeding, foreign bodies, or associated injuries may require more extensive treatment.
Providers diagnose the condition based on the patient’s history of trauma and physical examination, focusing on the wound. Imaging like X-rays may be used if a fracture or foreign material is suspected. Treatment can include stopping bleeding, cleaning and repairing the wound, applying medication and dressings, and pain relievers, anti-inflammatories, antibiotics, and tetanus prophylaxis if needed.
- Injury, poisoning and certain other consequences of external causes (S00-T88)
- Injuries to the head (S00-S09)
In simple words: An open wound of the head means a break in the skin of the head, usually with some bleeding.This includes injuries to the scalp, face, ears, eyes, mouth, and jaw areas.
Open wound of head.Includes injuries of ear, eye, face [any part], gum, jaw, oral cavity, palate, periocular area, scalp, temporomandibular joint area, tongue, and tooth. Code also for any associated infection.
Example 1: A patient presents with a laceration on their forehead after falling and hitting a sharp object., A patient is brought to the ER with a puncture wound on their scalp after being bitten by a dog., A child falls off their bike and has an open bite on their cheek.
Documentation should include the cause, location, and type of wound (laceration, puncture, bite, etc.), presence of foreign bodies, associated injuries (cranial nerves, muscles, tendons, intracranial), signs of infection, and treatment provided (cleaning, repair, medications).
** Excludes1: birth trauma (P10-P15), obstetric trauma (O70-O71). Excludes2: burns and corrosions (T20-T32), effects of foreign body in ear (T16), effects of foreign body in larynx (T17.3), effects of foreign body in mouth NOS (T18.0), effects of foreign body in nose (T17.0-T17.1), effects of foreign body in pharynx (T17.2), effects of foreign body on external eye (T15.-), frostbite (T33-T34), insect bite or sting, venomous (T63.4).
- Specialties:Emergency Medicine, General Surgery, Plastic Surgery, Family Medicine
- Place of Service:Emergency Room - Hospital, Office, Inpatient Hospital, Outpatient Hospital, Urgent Care Facility